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Brief Report
December 2016

Cardiac Stress Test Trends Among US Patients Younger Than 65 Years, 2005-2012

Author Affiliations
  • 1Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia
  • 2The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
  • 3Division of Cardiac Surgery, Hospital of the University of Pennsylvania, Philadelphia
  • 4Division of General Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia
  • 5Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Denver
  • 6Division of Cardiovascular Medicine, Veterans Affairs Eastern Colorado Health Care System, Denver
JAMA Cardiol. 2016;1(9):1038-1042. doi:10.1001/jamacardio.2016.3153
Key Points

Question  Are recently reported declines in rates of cardiac stress testing among Medicare beneficiaries and in a large health maintenance organization universal or confined to the populations studied?

Findings  In this serial cross-sectional study of a large cohort of commercially insured patients aged 25 to 64 years, we observed a 3.0% increase in the rate of cardiac stress testing from 2005 to 2012.

Meaning  Trends in cardiac stress testing may be driven more by unique characteristics of health systems and populations than by national efforts by physician groups to reduce overuse of testing.

Abstract

Importance  After a period of rapid growth, use of cardiac stress testing has recently decreased among Medicare beneficiaries and in a large integrated health system. However, it is not known whether declines in cardiac stress testing are universal or are confined to certain populations.

Objective  To determine trends in rates of cardiac stress testing among a large and diverse cohort of commercially insured patients.

Design, Setting, and Participants  A serial cross-sectional study with time trends was conducted using administrative claims from all members aged 25 to 64 years belonging to a large, national managed care company from January 1, 2005, to December 31, 2012. Linear trends in rates were determined using negative binomial regression models with procedure count as the dependent variable, calendar quarter as the key independent variable, and the size of the population as a logged offset term. Data analysis was performed from January 1, 2005, to December 31, 2012.

Main Outcomes and Measures  Age- and sex-adjusted rates of cardiac stress tests per calendar quarter (reported as number of tests per 100 000 person-years).

Results  A total of 2 085 591 cardiac stress tests were performed among 32 921 838 persons (mean [SD] age, 43.2 [10.9] years; 16 625 528 women [50.5%] and 16 296 310 [49.5%] men; 7 604 945 nonwhite [23.1%]). There was a 3.0% increase in rates of cardiac stress testing from 2005 (3486 tests; 95% CI, 3458-3514) to 2012 (3589 tests; 95% CI, 3559-3619; P = .01 for linear trend). Use of nuclear single-photon emission computed tomography decreased by 14.9% from 2005 (1907 tests; 95% CI, 1888-1926) to 2012 (1623 tests; 95% CI, 1603-1643; P = .03). Use of stress echocardiography increased by 27.8% from 2005 (709 tests; 95% CI, 697-721) to 2012 (906 tests; 95% CI, 894 to 920; P < .001). Use of exercise electrocardiography increased by 12.5% from 2005 (861 tests; 95% CI, 847-873) to 2012 (969 tests; 95% CI, 953-985; P < .001). Use of other stress testing modalities increased 65.5% from 2006 (55 tests; 95% CI, 51-59) to 2012 (91 tests; 95% CI, 87-95; P < .001). For individuals aged 25 to 34 years, rates of cardiac stress testing increased 59.1% from 2005 (543 tests; 95% CI, 532-554) to 2012 (864 tests; 95% CI, 852-876; P < .001). For individuals aged 55 to 64 years, rates of cardiac stress testing decreased by 12.3% from 2005 (7894 tests; 95% CI, 7820-7968) to 2012 (6923 tests; 95% CI, 6853-6993; P < .001).

Conclusions and Relevance  In contrast to declines in the use of cardiac stress testing in some health care systems, we observed a small increase in its use among a nationally representative cohort of commercially insured patients. Our findings suggest that observed trends in the use of cardiac stress testing may have been driven more by unique characteristics of populations and health systems than national efforts to reduce the overuse of testing.

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